Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oasis Pavilion Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A cognitively intact resident with multiple medical conditions had an abuse allegation reported by an outside complainant, who informed the Social Services Director that someone was allegedly trying to suffocate the resident with a pillow and that the resident was being forced to drink an unknown green substance. Although facility policy and staff statements indicated that any abuse allegation must be reported to the SA, APS, Ombudsman, and the Administrator within required time frames and investigated through interviews and documentation review, the Social Services Director did not notify any agencies or the Administrator and did not initiate an investigation, relying instead on the absence of abuse documentation in the medical record. The DON, an LPN, and the Administrator all reported that they were unaware of any allegation or investigation for this resident, and review of the written policy confirmed that the facility failed to follow its own procedures for reporting and investigating the abuse allegation.
A cognitively intact resident with multiple medical conditions allegedly experienced abuse involving someone placing a pillow over the face with a sour substance. A complainant reported this allegation by phone to the Social Services Director, who, contrary to facility policy and staff expectations, did not notify the SA, APS, Ombudsman, or the Administrator because she did not believe abuse had occurred based on the medical record. Other staff, including a CNA, an LPN, the DON, and the Administrator, reported that their understanding of policy was that all abuse allegations must be reported within specified time frames, but they were not informed of this allegation, and no self-report was made to state agencies.
A cognitively intact resident with multiple medical conditions was the subject of an abuse allegation reported by a complainant, who stated someone was trying to smother the resident with a pillow and that the resident was being forced to drink an unknown green substance. The Social Services Director, who along with the DON is designated to receive and investigate abuse complaints, acknowledged receiving the complainant’s call but did not initiate an investigation because there was no documentation of abuse in the medical record and instead assured the complainant that no abuse had occurred. The DON, Administrator, and an LPN all reported they were unaware of any abuse allegation or investigation for this resident. Review of the State Agency database confirmed there was no facility self-report or 5-day investigation report, despite facility policy requiring prompt reporting and investigation of all suspected abuse incidents.
A resident with an indwelling catheter had urinary outputs documented in the medical record for days when the resident was not present in the facility, following a hospital transfer. Staff interviews revealed confusion about documentation procedures during resident absences, and the DON confirmed that such documentation should not have occurred, as facility policy requires accurate daily output records.
A resident with multiple complex medical conditions experienced a significant change in condition, including altered mental status, tachycardia, hypotension, and oxygen desaturation. Staff failed to document updated vital signs, the type and timing of hospital transfer, and physician instructions, resulting in incomplete assessment, monitoring, and emergency response. Facility policy for emergency transfers was not followed, and the clinical record lacked necessary progress notes and documentation.
A resident with multiple health conditions developed a stage III sacral pressure ulcer that required specific wound care as ordered by a physician. The wound care orders, including the use of hydrogel and calcium alginate dressings, were not entered into the MAR or TAR, resulting in the treatment not being provided or documented. The LPN responsible for wound care acknowledged the omission, and the DON confirmed that treatments must be entered and documented according to facility policy.
A resident with multiple complex diagnoses experienced a change of condition, but staff failed to document the event, physician notification, physician instructions, and the details of the hospital transfer in the clinical record. Interviews revealed missing or unclear documentation regarding vital signs, the type and timing of the transfer, and the physician's involvement, despite facility policy requiring such records.
A resident with a history of falls and multiple diagnoses was inaccurately assessed as low risk for falls upon admission to an LTC facility. Despite hospital records and care plans indicating a fall risk, the fall risk assessment conducted by an LPN did not reflect this due to a misunderstanding of the assessment criteria. Interviews with staff, including a CNA, RN, and DON, highlighted discrepancies in the assessment process, leading to potential risks in resident care.
The facility failed to protect a resident with severe cognitive impairment from abuse by her newly admitted roommate, resulting in a fall and a new fracture of the resident's left femur. Staff interviews revealed gaps in the screening process for residents with behavioral issues.
Instances of resident-to-resident abuse were reported, highlighting deficiencies in protecting residents from harm. One incident involved a resident throwing a remote control, causing a bruise on another resident's leg. Despite interventions for the resident's impulsive behavior, the altercation occurred. Another case involved a resident being bruised by a motorized wheelchair operated by a resident with a history of impulsive behavior. The facility's documentation and witness statements indicated a lack of effective interventions to prevent these confrontations, despite existing care plans.
The facility failed to ensure the right to personal privacy for two residents. Staff entered rooms without knocking or waiting for a response, and did not introduce themselves, despite facility policy requiring these actions.
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records. An RN left an uncapped syringe, a pill cup, and an open EHR displaying resident information unattended. In another instance, the RN walked away from an unlocked EHR revealing residents' names. The ADON confirmed that nurses are expected to lock medication carts and EHR screens when stepping away.
The facility failed to update the care plan for a resident with anxiety disorder, major depressive disorder, and multiple sclerosis after an incident where the resident was mean to her roommate and used a motorized scooter to bump into the roommate. Staff interviews confirmed that the care plan should have been updated to address the resident's behavior and prevent further incidents.
A facility failed to ensure proper catheter care for a resident, leading to the catheter bag dragging on the floor and inconsistent care practices among staff. This put the resident at risk for urinary catheter complications and infections.
The facility failed to keep two of the four medication carts locked and under direct supervision, leaving an uncapped syringe and a pill cup filled with pills unattended. Additionally, two unlocked medication carts with accessible over-the-counter medications were found in an unlit alcove, posing a risk of unauthorized access by residents.
The facility failed to implement proper infection control practices during insulin administration. An LPN did not wipe the needle insertion site with an alcohol swab before administration. The ADON confirmed that nurses are expected to clean the insulin container and injection area with an alcohol swab, as per facility policy.
Failure to Report and Investigate Abuse Allegation as Required by Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, and misappropriation policy when an allegation of abuse/neglect was reported for one cognitively intact resident. The resident had been admitted with diagnoses including cerebral infarction, anemia, and malignant neoplasm of the bronchus or lung, and had a BIMS score of 14, indicating intact cognition, with documented verbal and other behaviors. A complaint was filed with the State Agency (SA) alleging that someone was trying to kill the resident by putting a pillow over his face with something sour on it. Review of the SA database showed that, although this external complaint was received, there were no corresponding self-reports from the facility regarding this allegation. The complainant reported contacting the facility’s Social Services Director on a specific date to notify her of the abuse allegation and concerns that the resident was being forced to drink “green stuff” and to ask about abuse in the building. The Social Services Director, who along with the DON is responsible for receiving abuse/neglect complaints and initiating reporting and investigations, acknowledged receiving this call. She stated she is required by policy to notify the SA, APS, Ombudsman, and the Administrator within required time frames and to initiate an investigation, including staff and resident interviews and suspension of involved staff if indicated. However, she did not notify any external agencies or the Administrator and did not initiate an investigation because she did not believe abuse had occurred, citing the absence of documentation in the progress notes or medical record. The DON, LPN, and Administrator each described the facility’s policy and regulatory requirement to report all abuse allegations to the SA within two hours and complete an investigation with findings reported within five days. They all stated that any allegation should be brought to the DON, Social Services Director, or Administrator and that an investigation and required notifications would then occur. Each of these staff members reported that no allegation regarding this resident had been brought to their attention prior to the surveyor interviews, and the LPN was unaware of any investigation related to the resident. Review of the written policy confirmed that any incident or suspected incident of abuse or unexplained injury must be promptly reported to designated facility leaders and appropriate agencies, and that all allegations must be investigated with interviews and written summaries. Despite these requirements, the allegation reported by the complainant to the Social Services Director was not reported or investigated in accordance with the facility’s policy.
Failure to Report Alleged Resident Abuse to Required Agencies
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #1 to all required state agencies. Resident #1 had diagnoses including unspecified cerebral infarction, unspecified anemia, and malignant neoplasm of an unspecified part of the bronchus or lungs, and a Brief Interview for Mental Status (BIMS) score of 14 indicating cognitive intactness. A complaint was filed with the State Agency (SA) alleging that someone was trying to kill Resident #1 by putting a pillow over his face with something sour on it. The complainant reported that she had notified the facility’s Social Services Director (Staff #35) by phone of this allegation. Review of the SA database showed no self-report from the facility regarding this allegation. Staff interviews revealed that CNAs and LPNs understood that allegations of abuse should be reported to supervisory staff such as the Social Services Director or DON, and that those leaders were responsible for notifying the Administrator, SA, Adult Protective Services (APS), Ombudsman, and police. Staff #35 acknowledged receiving the complainant’s call about possible abuse of Resident #1 but stated she did not notify SA, APS, Ombudsman, or the Administrator because she did not believe abuse had occurred, citing a lack of documentation in the progress notes or medical record. The DON and Administrator both stated they had not been informed of any abuse allegation regarding Resident #1 prior to the survey interviews. Facility policy required that any incident or suspected incident of abuse be promptly reported to appropriate agencies and facility leadership, and that all allegations of abuse be reported immediately to a direct supervisor or Social Services Director/DON/designee, including reporting to state agencies and the police, which did not occur in this case.
Failure to Investigate Reported Abuse Allegation
Penalty
Summary
The facility failed to fully investigate an allegation of abuse involving Resident #1. Resident #1 had diagnoses including unspecified cerebral infarction, unspecified anemia, and malignant neoplasm of an unspecified part of the bronchus or lungs, and a recent MDS showed a BIMS score of 14, indicating cognitive intactness, with documented verbal and other behaviors. A complaint was filed with the State Agency alleging that someone was trying to kill Resident #1 by putting a pillow over his face with something sour on it. The complainant reported that she had notified the facility’s Social Services Director (Staff #35) by phone of an abuse allegation involving Resident #1. Review of the State Agency database showed no self-report from the facility and no 5-day facility investigation report related to this allegation. Staff interviews and policy review showed that the Social Services Director and DON (Staff #68) were responsible for receiving and investigating abuse allegations, including interviewing staff and residents and suspending involved staff when indicated. Staff #35 acknowledged being contacted by the complainant about concerns that Resident #1 was being forced to drink “green stuff” and about possible abuse, but stated she told the complainant no abuse had taken place and did not initiate an investigation because there was nothing in the progress notes or medical record indicating abuse. The DON stated she was not informed of any abuse allegation regarding Resident #1 and that, had she been notified, an investigation would have been conducted and reported within 5 days per policy. The LPN (Staff #128) and the Administrator (Staff #37) both stated they were unaware of any abuse investigation for Resident #1, and the Administrator reported that no one had brought an abuse allegation regarding Resident #1 to his attention until the survey. Facility policy required that any incident or suspected incident of abuse be promptly reported to designated leadership and that all such incidents be investigated with interviews and written summaries, which did not occur in this case.
Inaccurate Documentation of Urinary Output for Absent Resident
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for one resident regarding urinary output. The resident, who had multiple diagnoses including muscle weakness, mobility issues, and both acute and chronic respiratory failure, was admitted with an indwelling catheter and an order for routine catheter care. Despite being transferred to the hospital and not present in the facility, the resident's Treatment Administration Record (TAR) showed documented catheter outputs for days when the resident was not in the facility. Interviews with staff revealed uncertainty about documentation procedures when a resident is out of the facility. The LPN was unsure if outputs should be recorded during a resident's absence, while the CNA stated that output documentation is only done when the resident is present. The DON confirmed that documentation of outputs should not occur when a resident is not in the facility and verified that incorrect entries were made in the resident's record. Facility policy requires maintaining an accurate record of daily output, which was not followed in this instance.
Failure to Assess, Monitor, and Document Emergency Response for Resident with Change in Condition
Penalty
Summary
The facility failed to ensure that a resident was properly assessed, monitored, and provided with an appropriate emergency response during a change in condition. The resident, who had multiple complex diagnoses including altered mental status, COPD, brain neoplasm, diabetes, hemiplegia, and slurred speech, was admitted with orders for oxygen therapy and regular monitoring of oxygen saturation. On the day of the incident, the last recorded oxygen saturation was 93% in the morning, but there was no documentation of further vital signs or oxygen levels in the afternoon when the resident's condition changed. Despite the resident exhibiting altered mental status, tachycardia, hypotension, and oxygen desaturation into the 80s, there was a lack of clear documentation regarding the assessment of the resident's condition, the timing and type of transfer to the hospital, and whether the transfer was emergent or non-emergent. Interviews with nursing staff and the DON revealed confusion and inconsistent accounts about who ordered the transfer, the resident's status at the time, and the communication with the medical provider. The hospital transfer form did not specify the time of transfer, the type of transfer, or provide updated vital signs at the time of transfer. Facility policy required that in the event of an emergency transfer, staff should call 911 if clinical criteria are met, document the resident's condition, and notify the attending physician. However, the clinical record lacked progress notes detailing the change in condition, updated vitals, and physician instructions. The deficiency was identified due to these omissions in assessment, monitoring, documentation, and emergency response for the resident experiencing a significant change in condition.
Failure to Provide Physician-Ordered Wound Care for Pressure Ulcer
Penalty
Summary
A resident with multiple diagnoses, including metabolic encephalopathy, malnutrition, dementia, and chronic kidney disease, was admitted and identified as being at risk for skin breakdown. Upon admission, the resident had a stage I pressure ulcer on the sacrum/coccyx and a stage II closed blister on the left foot. The care plan included interventions such as incontinence care, regular repositioning, and wound care as ordered by the physician. Orders were in place for wound cleansing, use of a low airloss mattress, application of barrier cream, and specific wound treatments for the left heel and buttocks. On December 24, a physician upgraded the sacral wound from stage I to stage III, noting the presence of eschar and necrotic tissue, and provided new wound care orders, including cleansing with wound cleanser, application of hydrogel ointment, and use of calcium alginate dressings. However, these new orders were not entered into the order summary, Medication Administration Record (MAR), or Treatment Administration Record (TAR). As a result, there was no documentation that the prescribed wound care was provided. The wound nurse acknowledged that the order for hydragel calcium alginate was not entered, and therefore, the treatment was not documented or performed as required. Interviews with the wound nurse and the Director of Nursing confirmed that the omission of the physician's wound care orders led to the failure to provide the necessary treatment. The facility's policy and the wound nurse's job description require that all physician orders be entered and carried out, and that treatments be documented. The lack of order entry and documentation resulted in the resident not receiving wound care in accordance with professional standards of practice.
Failure to Document Change of Condition and Hospital Transfer
Penalty
Summary
The facility failed to properly document a resident's change of condition, the notification of the physician, the physician's instructions, and the details of the hospital transfer in the clinical record. The resident in question had multiple significant diagnoses, including altered mental status, COPD, malignant neoplasm of the brain, type II diabetes, hemiplegia, and slurred speech, and was noted to have moderate cognitive impairment. On the day of the incident, the resident's oxygen saturation was last recorded in the morning, but there was no documentation of vital signs or oxygen levels at the time of the change of condition in the afternoon, when the resident was transferred to the hospital. Staff interviews revealed confusion and lack of clarity regarding the events leading up to the transfer. The DON acknowledged that there was no documentation of the resident's change of condition, vitals, or whether the physician had been notified or had ordered the transfer as emergent or non-emergent. The hospital transfer form did not specify the time or type of transfer, and staff were unable to confirm these details during interviews. The nurse practitioner later entered a late note indicating the resident was exhibiting altered mental status, tachycardia, hypotension, and oxygen desaturation, and that the resident was sent out via 911 for a higher level of care, but this was not contemporaneously documented. Facility policy requires prompt notification and documentation of changes in a resident's condition, including physician notification and recording of relevant information in the medical record. However, in this case, the required documentation was incomplete or missing, including the resident's condition at the time of transfer, the physician's instructions, and the specifics of the hospital transfer. This failure to document key aspects of the resident's care and transfer process constitutes the deficiency identified in the report.
Inaccurate Fall Risk Assessment in Resident's Health Record
Penalty
Summary
The facility failed to ensure that the electronic health record for a resident was complete and accurately documented, which could result in incomplete and/or inaccurate clinical records and potentially impact resident care. The resident was admitted with multiple diagnoses, including malignant neoplasm of the kidney, secondary malignant neoplasm of the brain, and a history of repeated falls. Despite this, the fall risk assessment conducted upon admission incorrectly indicated that the resident was at low risk for falls, with a score of '0'. This was inconsistent with the resident's documented history of falls in the hospital records, MDS, and care plan. Interviews with staff revealed discrepancies in the understanding and execution of the fall risk assessment process. A CNA mentioned that fall risk information is shared during shift changes and documented in the electronic health record. An RN stated that the fall risk assessment should include a review of the resident's fall history, interviews with the resident or family, and a review of hospital documentation. However, the LPN who conducted the assessment admitted to considering only the resident's fall history within the facility, not prior to admission, leading to the inaccurate assessment. The Director of Nursing acknowledged that the fall risk assessment should have identified the resident as a fall risk, as it should capture both current and historical information. The facility's policy on falls and fall risk management emphasizes the importance of identifying interventions based on previous evaluations and data to prevent falls. The failure to accurately assess the resident's fall risk could lead to staff confusion and inadequate precautions being put in place, as noted by the MDS nurse and the Director of Nursing.
Failure to Protect Resident from Abuse by Roommate
Penalty
Summary
The facility failed to ensure the right of one resident to be free from abuse by another resident. Resident #2, who has severe cognitive impairment and uses a walker for mobility, was admitted with a history of hypertension, strokes, and falls. On April 5, 2024, a nurse responded to calls for help and found Resident #2 on the floor, reporting that her roommate, Resident #1, had pulled her off the bed and pushed her to the floor. An x-ray taken the following day revealed a new fracture of Resident #2's left femur. Interviews with Resident #2 confirmed the incident, and the resident reported soreness and pain in the left hip area where the fracture was identified. Resident #1, admitted for palliative care with severe cognitive impairment, had no documented history of behavioral issues prior to the incident. The facility's investigative report noted that Resident #1 had been admitted only an hour before the incident occurred. Interviews with staff revealed that the facility typically does not admit residents with dementia and behavioral issues due to inadequate training. The Director of Nursing (DON) confirmed that the screening process for prospective residents is conducted by the Admissions Coordinator and herself, and that Resident #1's case manager had reported no behavioral issues. Despite this, the incident occurred, resulting in physical harm to Resident #2.
Resident-to-Resident Abuse Due to Impulsive Behaviors
Penalty
Summary
The report details instances where residents in the facility were subjected to abuse by other residents, leading to deficiencies in protecting residents from harm. In the case of resident #1 and resident #149, resident #149 threw a remote control at resident #1, resulting in a large bruise on her leg. Resident #149 exhibited impulsive behavior and outburst behaviors, leading to the altercation. Despite interventions in place for resident #149's behavioral symptoms, the incident still occurred, indicating a failure to adequately prevent resident-to-resident abuse. Similarly, resident #63 reported that resident #15 had bumped into her with a motorized wheelchair, causing a bruise on her knee. Resident #15 had a history of impulsive behavior, and the incident with resident #63 was not an isolated event, as similar behaviors had been displayed with previous roommates. The facility's failure to address resident #15's tendency to intimidate roommates or use the wheelchair to harm others contributed to the deficiency in protecting resident #63 from abuse. The facility's investigation reports, witness statements, and documentation highlighted the confrontations between the residents, indicating a lack of effective interventions to prevent resident-to-resident abuse. Despite the residents' cognitive statuses and care plans being in place, the incidents occurred, underscoring the need for improved monitoring, supervision, and intervention strategies to ensure the safety and well-being of all residents in the facility.
Failure to Ensure Resident Privacy
Penalty
Summary
The facility failed to ensure the right to personal privacy for two residents. Resident #6, who was admitted with diagnoses including unspecified injury of the head and generalized muscle weakness, reported that staff were either not knocking or not waiting for a reply before entering her room. An observation confirmed that a CNA entered Resident #6's room without knocking or waiting for a response, and did not introduce herself. The CNA admitted to not following the correct process of knocking and waiting for permission to enter the room. Similarly, Resident #79, who was admitted with cardiorespiratory conditions and coronary artery disease, reported that staff entered her room without knocking or waiting for her response. An observation confirmed that a CNA knocked once and entered Resident #79's room without waiting for a response. The CNA acknowledged that she did not wait for the resident's response before entering. The assistant Director of Nursing stated that staff are expected to knock, wait for a response, and introduce themselves before entering a resident's room. The facility's policy on Residents Rights emphasizes the right to personal privacy and respectful treatment.
Failure to Ensure Privacy and Security of Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records. During an observation, an uncapped syringe and a pill cup filled with an assortment of pills were left unattended on a medication cart. Additionally, the electronic health record (EHR) was left open and uncovered, displaying a resident's picture and list of medications. The registered nurse responsible for the medication cart and EHR was found in an alcove with another patient, leaving the medication and EHR screen out of her line of sight. In another instance, the same registered nurse walked away from the medication cart with an unlocked EHR that revealed a list of residents' names. The nurse was about to enter a resident's room for medication administration before being stopped to lock the EHR screen. The Assistant Director of Nursing confirmed that nurses are expected to lock the medication carts and EHR screens when stepping away. Facility policies reviewed indicated that unauthorized release, access, or disclosure of resident information is prohibited and that medication carts must be securely locked when not in the nurse's view.
Failure to Update Care Plan Following Resident Altercation
Penalty
Summary
The facility failed to ensure that the care plan for a resident was updated and revised as needed. Resident #15, who was admitted with diagnoses of anxiety disorder, major depressive disorder, and multiple sclerosis, was involved in an incident where she was reported to have been mean to her roommate, bumped into the roommate with a motorized scooter, and claimed control over the room. Despite this behavior, the care plan was not updated to address these issues or include interventions to manage the resident's behavior towards her roommates. Interviews with staff, including an LPN and the Assistant Director of Nursing (ADON), confirmed that the care plan should have been updated following the incident to mitigate further occurrences. The ADON acknowledged that the lack of an updated care plan could lead to repeated incidents and emphasized the importance of updating care plans to inform staff about the resident's needs. The facility's policies on care plans and abuse and neglect also support the need for timely updates and revisions to care plans based on changes in a resident's condition or behavior.
Failure to Ensure Proper Catheter Care
Penalty
Summary
The facility failed to ensure proper care and services related to an indwelling urinary catheter for a resident. The resident was observed with the catheter tubing exposed and the catheter bag dragging on the floor while being wheeled through the hallway. The Licensed Practical Nurse (LPN) acknowledged the incorrect placement and the associated risks of contamination and urinary tract infection (UTI). The resident also reported that catheter care was provided only once a day or when it itched, and during an interview, the catheter bag was again observed touching the floor while the resident was in bed. Further interviews with staff revealed inconsistencies in catheter care practices. A Certified Nursing Assistant (CNA) stated that catheter care was provided during each brief change and documented in the resident's electronic record. However, the CNA also acknowledged that the catheter bag should not touch the floor and should be placed below the resident's waist. The Registered Nurse (RN) and Assistant Director of Nursing (ADON) confirmed that the correct placement of the catheter bag was below the patient for easy flow and that the catheter tubing should not touch the floor. They also mentioned that catheter care training was provided regularly to staff. The facility's policy on urinary catheters and incontinence, reviewed and revised in January 2024, emphasized the importance of keeping the catheter tubing and drainage bag off the floor to prevent UTIs. Despite these policies, the observations and staff interviews indicated a failure to adhere to proper catheter care protocols, putting the resident at risk for urinary catheter complications and infections.
Failure to Secure Medication Carts
Penalty
Summary
The facility failed to keep two of the four medication carts locked and under the direct supervision of authorized staff. During an observation on March 6, 2024, an uncapped syringe and a pill cup filled with an assortment of pills were left unattended on a medication cart. Additionally, two unlocked and unsupervised medication carts were found in an unlit alcove of Hall B, with over-the-counter medications easily accessible in the top drawer of both carts. These observations were made in areas where residents could potentially access the medications, posing a risk of unauthorized ingestion. In interviews conducted with staff, the LPN acknowledged that a resident could take and ingest medications that were not theirs. The ADON confirmed that nurses were expected to lock the medication carts and the facility's EHR when stepping away. The facility's policy on Medication Administration, reviewed in October 2023, mandates that nurses must ensure the medication cart is securely locked at all times when not in the nurse's view. The failure to adhere to this policy was evident in the observations made during the survey.
Failure to Implement Infection Control Practices During Insulin Administration
Penalty
Summary
The facility failed to implement proper infection control practices during insulin medication administration. During an observation, an LPN did not wipe the single-resident use needle insertion site with an alcohol swab before placing the needle for administration. In an interview, the ADON confirmed that nurses are expected to clean the top of the insulin container and the skin injection area with an alcohol swab prior to administration. The facility's policy on Medication Administration also mandates the use of proper administration techniques, including maintaining sterility.
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Illustrative
What surveyors actually found near you
We read the 7 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Casa Grande
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caring House | 12.5 mi | — | 7 | 1 |
| The Center At Val Vista, Llc | 26.8 mi | — | 0 | 0 |
| Wellsprings Of Gilbert | 27.5 mi | — | 0 | 0 |
| Archstone Care Center | 28.5 mi | — | 4 | 0 |
| Sante Of Chandler | 28.5 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.